We appreciate the opportunity to comment on the proposed rule governing the application, review, and reporting process for waivers for state innovation. We are submitting these comments on behalf of thousands of members of the Healthcare Is a Human Right Campaign in Vermont, led by the Vermont Workers’ Center, a 501(c)3 organization based in Burlington.

As you will know, the state of Vermont has just passed a universal health care bill (H.202 of 2011), which sets the state on a path to a publicly financed health care system that will provide universal, comprehensive coverage to all residents, regardless of employment, income, assets or health status. This bill will enable Vermont to meet all requirements of the Affordable Care Act (ACA). The bill also states that in order to provide health care to everyone, on an equal basis, the state must exceed the standards of the ACA and adopt stronger provision for universal comprehensive coverage, affordability, and cost savings. For this reason, H.202 requires Vermont to apply for a State Innovation Waiver in order to make the implementation of this universal health system possible. The passage of this bill was driven by the will and demands of the people of Vermont, many of whom have come together in the Healthcare Is a Human Right Campaign to work toward a universal, equitable health care system that delivers care as a public good for all.

Given Vermont’s statutory intention of providing universal, equitable coverage under a publicly financed health care system, it is essential that the regulation for State Innovation Waivers does not create unnecessary obstacles — either procedural or substantive — for states that seek to exceed the standards of the ACA. Therefore, please consider our following suggestions for ensuring that the regulation is able to support states that seek to exceed federal standards.

Application Procedures (31 CFR 33.108 and 45 CFR 155.1308)

In this section, comments are solicited on whether a state should be required to submit an application at least 12 months in advance of the requested effective date. We recommend a shorter waiting period. 12 months is a long time in the life of an uninsured person or someone with a bare-bones coverage plan they cannot afford to use. If a state has proved in its application that it can increase coverage and affordability while saving costs, that state should be allowed to implement these innovative, potentially life-saving measures as soon as possible in order to protect its populations’ health.

Periodic Evaluation Requirements (31 CFR 33.128 and 45 CFR 155.1328)

In this section, comments are solicited regarding specific components of the periodic evaluation of a section 1332 waiver. It is stated that among the potential components of a periodic evaluation could be the impact of the waiver on the choice of health plans for individuals and employers. We recommend dropping this criterion, because a universal health plan, which by definition is one plan for everyone, would not be able to meet this criterion. We wish to point out that “choice of health plans” is only applicable to the context of a private, market-based health care system in which health plans are sold for profit by private companies. In a universal system, everyone would have access to the same comprehensive benefits, under the same rules — and therefore the same plan. In such a system, there would be no stratification, no tiers of different benefits and costs; instead, everyone would be treated equitably, with costs and benefits shared by all according to their needs. It is in fact the choice of health care providers that matters to patients, rather than a spurious choice between plans that in effect all restrict access to providers. Therefore, we recommend replacing the proposed criterion “choice of plans” with a criterion that measures access to actual health services, especially by vulnerable or otherwise underserved populations.

Respectfully submitted,

David Kreindler
for the Healthcare Is a Human Right Campaign
Vermont Workers’ Center
294 North Winooski Avenue, Burlington VT 05401